Provider Demographics
NPI:1669682167
Name:MADSEN-BIBEAU, JOHN R (MS, LMFT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:R
Last Name:MADSEN-BIBEAU
Suffix:
Gender:M
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 EDGEMERE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-1004
Mailing Address - Country:US
Mailing Address - Phone:860-231-7138
Mailing Address - Fax:
Practice Address - Street 1:157 GRAPE STREET
Practice Address - Street 2:RIVER VALLEY COUNSELING
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01030
Practice Address - Country:US
Practice Address - Phone:413-594-2141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106H00000X
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
43935OtherAAMFT MEMBER #